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THE PERSON COMPLETING THIS DOCUMENT MUST BE THE AT&T ACCOUNT HOLDER AND MUST PROVIDE A COPY OF THEIR
VALID PHOTO ID.
1 Print, fill out and sign the Sworn Affidavit & Proof of Loss Statement.
Found on page 2 of this document.
2 Scan or take digital pictures of both the completed affidavit and your valid photo ID.
3 Upload both documents at phoneclaim.com/att-uploader
Fax
1 Print, fill out and sign the Sworn Affidavit & Proof of Loss Statement.
Found on page 2 of this document.
2 Photocopy your valid photo ID and handwrite your wireless number on each page.
3 Fax both documents to 1-888-429-7719.
AT&T Mobile Protection Pack consists of Mobile Insurance, Enhanced Support and Mobile Locate. *Mobile Insurance is underwritten by Continental Casualty Company, a CNA company (CNA), and
administered by Asurion Protection Services, LLC (In California, Asurion Protection Services Insurance Agency, LLC, CA Lic. #OD63161. In Puerto Rico, Asurion Protection Services of Puerto Rico,
Inc.), a licensed agent of CNA. All applicable taxes and surcharges extra.
For your protection, a person who knowingly presents a false or fraudulent insurance claim with the intent
to injure, defraud, or deceive any insurer is guilty of a crime and may be subject to fines and confinement
in prison. When fraud is discovered, Asurion takes appropriate steps to stop such fraud and explores all
of its available legal remedies.
ALL FIELDS ARE REQUIRED. PLEASE PRINT USING BLUE OR BLACK INK
Wireless Number:
Manufacturer:
( Examples: Apple, Samsung, LG, etc. )
Model:
( Examples: iPhone6, GalaxyS5, G3, etc.)
Lost
Date of Occurrence:
Stolen
Damaged
Malfunctioning
Place of Occurrence:
Note: If your device was damaged or malfunctioning, you are required to return it to Asurion upon receipt of your replacement.
Email Address:
Billing Address:
City:
State:
Zip Code:
Claim agreement
I swear/affirm that the device I am claiming is owned by me and that the information provided above is true and accurate. I understand that knowingly presenting false or fraudulent
information in support of this insurance claim with the intent to injure, defraud, or deceive any insurer is a crime. Asurion may take legal action, including reporting to law enforcement,
when it suspects fraud in the presentation of insurance claims.
Signature:
Control # F-017-48-AEN Rev 24 EDT:11/1/07 RDT: 12/4/14
Date:
Web: phoneclaim.com/att-uploader Fax: 1-888-429-7719
Asurion Attn: Review Team P.O. Box 413886 Kansas City, MO 64141-3886